Evidence suggests that the number of suicides in the UK is under-reported, and this may mean preventative services suffer as a result. By Colin Pritchard.
The tragedy of suicide is that it is double-edged: the loss of the person and the impact upon those around them. The late Elizabeth Barraclough – my grandmother – once said: “I have lost husband, mother and father, brothers and sister, but nothing, nothing, is more bitter than losing a bairn [child].” This is the nightmare of every parent, but imagine if you lost a child by its own hand. Research tells us of the distress and unresolved guilt faced by close family members and friends after a suicide. But consider the emotional reality of how such words are so bland in face of the stark bitter reality of such a loss.
The professional too feels the anxiety that surrounds assessing suicide risk, but it is nothing like the stress of visiting a family of a suicide. Key workers well know the guilt we can feel – about the extra mile we might have gone, how we should have recognised earlier the level of distress or confounded by the unexpectedness of the outcome. Sometimes the family want to blame us because they have to live the ‘ultimate rejection’ that is suicide.
Family interactions will vary as to who is the victim: parents mourning a child; siblings shattered by the loss of their brother or sister, or an adolescent or young adult, shocked by the death of a parent. But this only focuses upon the intra-family aspects; what is often forgotten are socio-economic triggers, such as unemployment. As was found back in the 1980s and through the 1990s and current recessions, suicide rates go up and down with employment throughout the Western world (Pritchard, 1990; 1996; Pritchard & Hansen, 2008).
This socio-economic factor can make uncomfortable reading for governments during economic crises. It is also allied to the continuous cultural stigma that still surrounds suicide, often because of religious attitudes.
There is evidence that governments across the world would rather not discuss suicide, especially that of youth and young adults (Pritchard & Amanulla, 2007; Pritchard et al, 2013). Consequently, it has been that many official national suicide rates hide underreported suicide (URS) deaths.
In part this is because coroners, wishing to spare the grieving family further distress, might be inclined to give either an accidental or an open verdict where it was uncertain whether the death was an accident, possible third party or self-inflicted.
Such a verdict is then recorded in World Health Organization (WHO) mortality statistics as ‘Undetermined’ (UnD). One reason why UnD are a likely source is that they have very similar methods of ‘lethality’ as suicides – drowning, falling, overdose, road death etc. Some have shown that surveys of suicides should include these UnD deaths and recently the Office for National Statistics has responded by including UnD rates along with the numbers of reported suicides.
But why does this matter, is this just the sort of number crunching beloved of academics and bureaucrats?
It matters enormously because it is clear that suicide rates go up and down reflecting social as well as individual psychosocial health. However, if we do not understand the extent and size of the problem, there will be little political will to seek a more effective preventive program.
What follows might shock or indeed offend but there can be few people in the world who did not know of the horror of the atrocity of 9/11, when 2,997 innocent people were murdered. The political ramifications continue to this day. But as a public health problem, it does not compare to the annual toll of suicides.
In 2001, there were more than 4,000 suicides in Britain and in excess of 30,000 in the USA. Since that terrible event, an examination of WHO data shows there have been 41,800 UK suicides and 383,690 in America – yet no headlines.
In one sense these are relatively ‘silent deaths’, which is another aspect of societal and political response to the ‘ultimate rejection’. It is easier or perhaps preferable to reject the problem by ignoring it, and saying nothing can be done, it’s up to individuals, or inevitable market and societal pressures that lead to the desperation of suicide against which governments are helpless.
By ignoring the extent of even the official figures, governments perpetuate the stigma and, worse, by failing to recognise the extent of the chronic epidemic, not only are there inadequate preventative programs, but we leave the bereaved to deal with the irresolvable distress of what author Alison Wertheimer called ‘the special scar’ (2001).
Sources of under-reported suicides
Moreover, there is considerable evidence that bereavement through suicide has subsequent health and psychosocial cost to friends and family. In a new study, consultant psychiatrist Lars Hansen and I offered an evidence-based challenge to a number of Western nations as we believe we discovered the likely source of URS and that the UK tops the league of 20 Western nations for it (Pritchard & Hansen, 2015).
We analysed suicides, accidental deaths and UnD by age and sex to find UK youth (15-24) suicides for both sexes was the same as the number of UnD – a ratio of 1:1: no other country had such a narrow ratio. We argued that that ratio of one UnD to five suicides or less would be indicative of possible URS. In a modern world with our advanced technology one would expect that UnD would be far lower than suicides.
Furthermore, the UK had a disproportionally higher UnD in every age band and closer suicide to UnD ratios than any other country, strongly indicating our rates are markedly under-reported.
Other countries with likely higher URS were Portugal and Switzerland, while various countries had suspiciously high UnD for women or older people. The European country with the lowest reported suicide is Greece. This is likely because of its Greek Orthodox traditional attitudes, where in some rural areas a suicide is buried outside ‘hallowed ground’ because they and the Roman Catholic Church state that a suicide is a cardinal sin.
Moreover, they report no UnD but their accidental death rates are far far higher than any other Western country. Of course, with traditional Catholic countries, such as those in Latin America they too have a distorted level of UnD, as do most Islamic countries – in the Quran suicide is explicitly seen as murder (Pritchard & Amanulla, 2007; Pritchard et al, 2013).
The practical implications of these results means the problem of suicide is being seriously underreported, making it easier to make cuts to mental health services, which compounds these tragedies.
This angers me because there used to be another ‘hidden’ under-reported epidemic of violent deaths, namely road deaths, which in the 1970s hit 7,000 a year. But today, there are less than 2,500 because a technical revolution, pressures from the insurance companies and the cost of emergency and continuing healthcare of survivors was sufficient incentive for governments to bring in legislation to improve road safety. All made a major impact on the annual death toll and what was done for road safety could be done for mental health.
Moreover, when one takes a broader view of mental health, we find a staggering connection with the extremes of child abuse-related deaths (Pritchard et al, 2013). Indeed, when one lists factors associated with suicides, quite apart from the obvious mental health link, the homeless – of whom a large majority are former psychiatric patients – drug and substance abusers, victims of child sex abuse, prison inmates (again the link with poor mental health) as well as the unemployed, reflect the shortcomings of mental health services – not the frontline workers but successive governments who have failed to tackle the problem.
We have urged colleagues to recognise the child development and protection-psychiatric interface, because as we relatively neglect the mentally ill, we also neglect their children (Pritchard et al, 2013). We also ignore the research evidence that shows that having a mentally ill parent impairs the child bio-psycho-social development. Colleagues sometimes suggest this adds stigma to the mentally ill, failing to recognise what is beginning to be seen in Norway and Germany that the best prevention of mental health problems is to support the children of psychiatric parents. This has recently become mandatory in Norway and research shows we can make a measurable difference.
Consequently, it is argued that we should stop thinking of limited child protection objectives and recognise the child’s essential role is to develop, and anything that impairs a child’s development is a form of neglect. If we took an integrated view of child development and protection along with mental health, we could begin to adjust the imbalance of mental health care. This may seem a long way from the issue of ‘suicide’ but it is part of the ramifications of mental disorders and illness.
Suicide is at the extreme but if under-reporting continues nothing gets done. We need an integrated policy that brings together concern for child development and protection and the link with mentally ill and disordered parents. There should be an equal alliance between child protection and mental health services. With an integrated approach we could begin to make inroads into the annual toll of suicides as well as reach out to families with mental Illness and help them develop their children better.
Pritchard C (1990) Suicide, Unemployment & Gender Variations in the Western World 1974–1986: Are Women in Anglophone Countries Protected from Suicide? Social Psychiatry Psychiatric Epidemiology 25 73–80.
Pritchard C (1996) Suicide the Ultimate Rejection: A Psycho-social study. Buckingham: Open University Press.
Pritchard C & Hansen L (2008) Consistency in suicide rates in twenty-two developed countries by Gender over Time 1874–78, 1974–76 and 1998–2000. Archives of Suicide Research 12 251–262.
Pritchard C & Amanulla S (2007) An analysis of suicide and undetermined [Other Violent Death] deaths in 17 predominately ‘Islamic countries’ contrasted with the United Kingdom. Psychological Medicine 37 421–430.
Pritchard C, Roberts S & Pritchard CE (2013) ‘Giving a Voice to the Unheard’? Is Female Youth (15-24 years) Suicide linked to restricted access to family planning? Comparing Two Catholic Continents. International Social Work 65 797–514.
Pritchard C & Hansen L (2015) Examining Undetermined and Accidental Deaths as source of ‘Under-Reported –Suicide’ by age and sex in twenty Western countries. Community Mental Health Journal 51 365–76.
Pritchard C, Davey J & Williams R (2013) Who kill children? Re-examining the evidence. British Journal of Social Work 43 1403–1438.
Wertheimer A (2001) A Special Scar: The Experiences of People Bereaved by Suicide. Hove: Brunner-Routledge
About the author
Colin Pritchard is a research professor in psychiatric social work at the Faculty of Health & Social Sciences, Bournemouth University